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Guidelines

Pharmacologic Treatment

Pharmacologic treatment alone should not be relied upon for treatment of chronic pain, but rather used as an adjunct to patient engagement and other modalities. Pharmacologic treatments should be initiated to increase function and restore a patient’s overall quality of life, not just pain relief. Medications are not the focus of treatment in managing pain. They should be used when needed to meet overall goals of therapy in conjunction with other treatment modalities, such as psychosocial, rehabilitation and functional management, non-pharmacologic, complementary medicine and interventional management.

General principles for pharmacologic management (Wisconsin Medical Society Task Force on Pain Management, 2004)

  • A thorough medication history is critical to the development of an effective treatment plan. This should include prescription medications, over-the-counter medications, herbals and supplements.
  • Base the initial choice of medication(s) on the severity and type of pain, as well as patient specific factors including age, co-existing diseases, other current medications and medication history.
  • Define the goals of therapy before prescribing, and tailor medications to meet the individual goals of each patient by using shared decision-making.
  • Look for medication-related fears and misconceptions, as they may lead to poor compliance with a therapeutic regimen.
  • Give medications an adequate therapeutic trial. When treating inflammatory or neuropathic pain, benefits may take weeks or longer to appear.
  • Patients need to know that whether prescribed or non-prescribed, all medications have risks and benefits. Watch for and manage side effects.
  • Rational poly-pharmacy, or multi-nodal analgesia, includes the use of two or more medications with complementary mechanisms of action that may provide greater pain relief with less toxicity by using lower doses of each medication. However, avoid prescribing two medications in the same class at the same time. Use the least invasive route of administration, preferably oral.
  • Be alert for additive side effects and possible interactions with other medication the patient is taking. Titrate doses to achieve optimal balance between analgesic benefit, side effects and functional improvement. Some medications require gradual upward titration to achieve optimal analgesia and to minimize adverse effects.
  • Taper and discontinue medications that do not produce the desired therapeutic outcome and do not meet the treatment goals. This practice helps to prevent expensive and potentially dangerous poly-pharmacy.

Non-Opioid Medications:

The following non-opioid medication classes may be used for pain treatment.

  • Acetaminophen
  • Anticonvulsants
  • Antidepressants
  • Glucocorticosteroids
  • Muscle relaxants and antispasmodics
  • Non-steroidal anti-inflammatory drugs (NSAIDs)

See Appendix B, “Non-Opioid Pharmacology,” for details about each of these classes, including names of medications, indications, general mechanism, common adverse events, contraindications and monitoring parameters.

The work group does want to highlight one recommendation related to non-sedative and sedative hypnotics benzodiazepines and muscle relaxants.

Opioid Medications

For more information on opioid pharmacology, including names of medications, indications, mechanism of action, common adverse effects, contraindications, hepatic/renal dosing, opioid utilization, as well as individual medication details, see Appendix C, “Opioid Pharmacology.”  The following section provides an in-depth discussion of opioid management.

ICSI

ICSI